Re: Doctor getting kickbacks?
h
"peewee" <pewee_...@gmail.com> wrote in message
news:hq5dlj$3rq$1...@speranza.aioe.org...
>I am contemplating surgery. I have a surgeon that uses one of
> the outpatient surgery centers to do his work and he
> typically does thousands of the same operation a year at this
> same place.
>
> I have reason to think he maybe have a financial interest if
> not outright getting kickbacks from this surgery center and
> he is very closed about disclosing costs associated with
> surgery.
>
> Is there a way, short of taking him to court that I can
> determine if he has a financial interest in this center where
> he does his cutting?
Umm, why does it matter? He has a right to make whatever deals he likes with
whomever he chooses. You have the right to know all costs before you
purchase. No one in their right mind buys something before they know the
cost. If he won't tell you what it will cost, tell him you'll go some place
else. Then, if he still won't tell you, go some place else. You can't sue
him just because he has "relationships" with other organizations. Sheesh.
What are you, 12?
Samantha Hill
> I am contemplating surgery. I have a surgeon that uses one of
> the outpatient surgery centers to do his work and he
> typically does thousands of the same operation a year at this
> same place.
I have a suggestion. Ask him if he has a different recommendation of
where to have the surgery done and why he chooses that one center, and
if he had a second preference if you could not get your surgery done
there, who would he recommend.
Alternatively, call the surgery center and ask them if the doctor has a
financial interest in it because you are personally opposed to having
surgery there if he is getting a kickback.
He may prefer that center because they are easier to work with, because
it takes the largest variety of insurance plans, or a whole myriad of
other perfectly valid and reasonable reasons.
The physician I worked for did the vast preponderance of procedures at
one outpatient surgery center because they never gave him a hard time
about scheduling, they always had the right equipment there for the
procedures he needed to do, etc. And he did a lot of workers' comp
procedures there, and worker's comp guidelines generally state that a
physician cannot do surgery on a workers' comp patient at a facility
where the physician has a financial interest. He did have three or four
other locations that he had privileges at and would do procedures at if
he had to, and he might have had a vested interest in one or more of
them, but he did not prefer to use them, usually for reasons like they
didn't have the equipment that he needed to do the procedures (even
though he gave them a list, and one time he didn't find this out until
he had already started and had to make do with something else), they
would cancel blocks of time he had reserved without letting him know,
the facility had a poor track record of getting insurance to pay for the
procedures that were covered by the patient's insurance policy, etc.
Bill
>I am contemplating surgery. I have a surgeon that uses one of
> the outpatient surgery centers to do his work and he
> typically does thousands of the same operation a year at this
> same place.
>
> not outright getting kickbacks from this surgery center and
> he is very closed about disclosing costs associated with
> surgery.
>
> Is there a way, short of taking him to court that I can
> determine if he has a financial interest in this center where
> he does his cutting?
What matters is if in fact you need the surgery or not. Get a second opinion
if you are not sure.
If there is a financial interest and he is recommending unnecessary surgery
just to make more money, then THAT is a problem. (silly question because
they make tons of money each time they operate no matter where!)
If you DO need the surgery, then best to let him operate where HE wants to
operate. He would be used to working with certain people and they would be
where he regularly works. As with anyone else, he probably would not be able
to do as good of a job in a strange environment working with people he is
unfamiliar with.
And in some cases, this could mean the difference between living through the
surgery or not! With certain surgery like heart operations, time is of the
essence. The surgery will be done in a short period of time if there is a
"well oiled machine" (fast team of workers who are used to working with each
other). If it is with workers unfamiliar with each other, the surgery could
take twice or three times longer! And that would mean serious damage and
maybe death to certain patients. The "survival" statistics are higher with
the fast team...
Roy
> I am contemplating surgery. I have a surgeon that uses one of
> the outpatient surgery centers to do his work and he
> typically does thousands of the same operation a year at this
> same place.
>
> I have reason to think he maybe have a financial interest if
> not outright getting kickbacks from this surgery center and
> he is very closed about disclosing costs associated with
> surgery.
>
> Is there a way, short of taking him to court that I can
> determine if he has a financial interest in this center where
> he does his cutting?
It varies by state. Some states require the doctor to tell you if he
holds a financial interest in the surgery center.
Kickbacks are usually illegal. Holding a financial interest in the
facility is not.
You might ask the doctor what his second choice of location for the
surgery is.
Samantha Hill
>
> The fact that a doctor will not disclose costs is sufficient
> in my opinion to deny him a license to practice medicine.
> These are people, not Gods, they are not allowed to play
> under a different set of rules than the rest of us. Not
> disclosing costs is dishonest, plain and simple.
Well, as someone who has worked in the medical field for 18 years, how
much it costs truly depends on what insurance the patient has, assuming
that the patient wants to know how much it will cost him/her. And even
if the insurance company gives you an estimate of the costs up-front,
that doesn't mean that even if they approve the surgery they won't come
back after the fact when you submit the claim for it and say, "Sorry,
we're not paying for that," and there is not a whole bunch the doc can
do except appeal the claim denial and see if he can convince the
insurance company to pay for it -- which, if they won't, will mean that
the patient now will have to pay a lot more to cover what the insurance
company reneged on.
Joh...@badisp.org
You're probably correct and this is one of the things the recent
health care reform should have corrected but probably didn't. It's
disgraceful and really not understandable why the courts won't
intervene and stop these practices. If you ask for your car to be
repaired and the garage gives you a quote that's the maximum they can
collect. Why should the human/doctor be any different?
The MD should provide a quote in writing after asking the insurance
company. If later on they renege (or so he says) he (the MD) eats it!
BTW that's how it works for my dentist. He says (say) he's got to put
in a crown at [tooth number]; he sends all the paperwork and x-rays to
the insurance company and they approve in advance in writing telling
him how much he has to collect from me (the customer). He says he's
never had a problem with the insurance company not paying later on and
if they didn't he would consider that between him and them, nothing he
could recharge to the customer.
Samantha Hill
>
> You're probably correct and this is one of the things the recent
> health care reform should have corrected but probably didn't.
Probably not, because I think the insurance companies had a lot of
input, and the insurance
> It's
> disgraceful and really not understandable why the courts won't
> intervene and stop these practices. If you ask for your car to be
> repaired and the garage gives you a quote that's the maximum they can
> collect. Why should the human/doctor be any different?
Oh, my doc could absolutely give fixed quotes for cash prices for office
visits and procedures. It's what the patient ends up paying after
insurance is no guarantee. And I doubt that your local mechanic ever
has to tell you what you will end up paying after your insurance company
pays. Not only that, but a car has a finite and constantly decreasing
value. Can you see some insurance company saying, "I'm sorry, you have
maxed out your lifetime benefits for health care and we are 'totalling'
you. We will settle your case for $$ and you will have to take care of
any further medical costs out of your pocket for the rest of your life;
alternatively, if you present to the local euthanasia center for
disposal and provide proof, you can get a higher figure for being
totalled and disposed of." That sounds pretty immoral and intolerable
to me. And that is why health insurance is so different than medical
insurance.
Now, if health insurance worked like car insurance, then the patient
would have to pay the bill and then be reimbursed by the insurance
company, or the insurance company would have a fixed amount they would
pay and they could pay it to the insurance company no questions asked.
Unfortunately, the doc's office is not allowed to bill the patient until
he has first billed the primary insurance, then after the primary
insurance has paid he has to bill any secondary insurance (and if the
patient messed up on giving the doc's office the proper insurance, that
gets all messed up) Auto insurance sure doesn't work that way.
> The MD should provide a quote in writing after asking the insurance
> company. If later on they renege (or so he says) he (the MD) eats it!
Actually, I think that if the insurance company says, "We will authorize
this procedure and pay $$$ as per our contracted rate," then they should
be made to pay it. Why should the doctor suffer because the insurance
company changed its mind? He/she shouldn't any more than you should
have to work for a week at no pay because your boss forgot to set aside
the money for payroll.
> BTW that's how it works for my dentist. He says (say) he's got to put
> in a crown at [tooth number]; he sends all the paperwork and x-rays to
> the insurance company and they approve in advance in writing telling
> him how much he has to collect from me (the customer). He says he's
> never had a problem with the insurance company not paying later on and
> if they didn't he would consider that between him and them, nothing he
> could recharge to the customer.
The problem is that getting a crown is a small cost compared to medical
care and some procedures and surgeries that need to be done to treat
diseases, not to mention the fact that the doctor probably doesn't do a
crown in a hospital or in an ambulatory surgery center with their own
expenses. A half-million dollar organ transplant compared to a
thousand-dollar crown, you know? Apart from that, there are far fewer
people with a sense of entitlement about dental insurance than about
medical insurance.
I think that if the insurance companies dealt directly with the patients
and just reimbursed the patients for allowable costs instead of the
doctors having to fight with them about getting paid, then it wouldn't
be quite such a tangled mess for anybody.
h
>>
>
> "h" and "Bill" are the same person posting under different
> IDs-look at their news reader clients and other info.
>
>
Umm, no, I am most certainly not "Bill", being female and all.
Joh...@badisp.org
>Joh...@BadISP.org wrote:
>> You're probably correct and this is one of the things the recent
>> health care reform should have corrected but probably didn't.
>Probably not, because I think the insurance companies had a lot of
>input, and the insurance
It's not the evil insurance companies who are at fault; it's the evil
doctors.
>> It's
>> disgraceful and really not understandable why the courts won't
>> intervene and stop these practices. If you ask for your car to be
>> repaired and the garage gives you a quote that's the maximum they can
>> collect. Why should the human/doctor be any different?
>Oh, my doc could absolutely give fixed quotes for cash prices for office
>visits and procedures. It's what the patient ends up paying after
>insurance is no guarantee.
No reason (other than the MD's greed and incompetence) why it
shouldn't be.
> And I doubt that your local mechanic ever
>has to tell you what you will end up paying after your insurance company
>pays.
I don't have any insurance for repairs to my car. If you're talking
about body work where an insurance company may be involved you're
absolutely wrong! Depending on the insurance, you might have an
insurance-owned body shop which does the work with no cost to you
other than the deductible or a private shop which negotiates an amount
(usually a quote) with the insurance company usually via a loss
assessor. No surprises!
> Not only that, but a car has a finite and constantly decreasing
>value. Can you see some insurance company saying, "I'm sorry, you have
>maxed out your lifetime benefits for health care and we are 'totalling'
>you. We will settle your case for $$ and you will have to take care of
>any further medical costs out of your pocket for the rest of your life;
>alternatively, if you present to the local euthanasia center for
>disposal and provide proof, you can get a higher figure for being
>totalled and disposed of." That sounds pretty immoral and intolerable
>to me. And that is why health insurance is so different than medical
>insurance.
No your gobbledygook above is not the reason why car insurance and
health insurance are different and none of the points you raise effect
the basic principle that the amount of any procedure should be quoted
in advance and the customer should be able to rely on the amount.
>Now, if health insurance worked like car insurance, then the patient
>would have to pay the bill and then be reimbursed by the insurance
>company, or the insurance company would have a fixed amount they would
>pay and they could pay it to the insurance company no questions asked.
This doesn't make sense.
>Unfortunately, the doc's office is not allowed to bill the patient until
>he has first billed the primary insurance, then after the primary
>insurance has paid he has to bill any secondary insurance (and if the
>patient messed up on giving the doc's office the proper insurance, that
>gets all messed up) Auto insurance sure doesn't work that way.
You've already been told that this is not true but again you try and
divert attention from the obligation of the MD to quote in advance.
>> The MD should provide a quote in writing after asking the insurance
>> company. If later on they renege (or so he says) he (the MD) eats it!
>Actually, I think that if the insurance company says, "We will authorize
>this procedure and pay $$$ as per our contracted rate," then they should
>be made to pay it.
Perhaps because the insurance company and the MD have a contract? Ya
know, the "contracted rate" you refer to. If they agree to an amount
and then don't pay, the MD's argument is with the insurance company
not the customer.
> Why should the doctor suffer because the insurance
>company changed its mind? He/she shouldn't any more than you should
>have to work for a week at no pay because your boss forgot to set aside
>the money for payroll.
Nothing to do with it.
>> BTW that's how it works for my dentist. He says (say) he's got to put
>> in a crown at [tooth number]; he sends all the paperwork and x-rays to
>> the insurance company and they approve in advance in writing telling
>> him how much he has to collect from me (the customer). He says he's
>> never had a problem with the insurance company not paying later on and
>> if they didn't he would consider that between him and them, nothing he
>> could recharge to the customer.
>The problem is that getting a crown is a small cost compared to medical
>care and some procedures and surgeries that need to be done to treat
>diseases, not to mention the fact that the doctor probably doesn't do a
>crown in a hospital or in an ambulatory surgery center with their own
>expenses.
A ha, now we get to some of the real reason. I'll agree that the
system is screwed up in that there should be one bill: hospital,
nurses, x-rays, elevator riding charge <g> and the primary physician.
All these people have to bought under the same umbrella and the most
logical one is the primary physician. IOW he should employ the
hospital, the nurses, the radiologist, the lab, etc and pay their
bills and then reclaim the amount from the insurance company and his
customer. I don't pay the lab that constructs the crown separately:
the dentist pays them.
And this is actually the crux of the matter. I don't give the MD any
licence to employ anyone on my behalf any more than I give the auto
mechanic any agency to employ (say) a super-duper automotive engineer
who then charges me a consulting fee. If he (the automotive engineer)
tried to do this I'd tell him to put it where the sun don't shine and
I don't believe contract law would require me to pay. Why this changes
when it's the medical industry I don't understand.
> A half-million dollar organ transplant compared to a
>thousand-dollar crown, you know? Apart from that, there are far fewer
>people with a sense of entitlement about dental insurance than about
>medical insurance.
The amount is not the problem. It's the principle.
>I think that if the insurance companies dealt directly with the patients
>and just reimbursed the patients for allowable costs instead of the
>doctors having to fight with them about getting paid, then it wouldn't
>be quite such a tangled mess for anybody.
Fine by me but this doesn't alter the "each party who want to work on
me has to quote a $ amount and not exceed that and has to get my
permission preferably in writing" idea.
tmclone
>
> "h" and "Bill" are the same person posting under different
> IDs-look at their news reader clients and other info.
>
Umm, no, "h" and I are the same person posting on different machines.
Neither "h" nor I am "Bill".
Rod Speed
Essentially because its nowhere near as easy to predict
what total services the individual needs with a serious
medical problem, like for example when the individual
ends up with a very serious infection that costs a hell
of a lot to fix. You dont get anything like that with cars.
> The MD should provide a quote in writing after asking the insurance
> company. If later on they renege (or so he says) he (the MD) eats it!
It cant work like that with major surgery. There is always the possibility
of a very serious infection or even once the individual is opened up, the
surgeon discovers that the individual has a much more complicated
physiology than was expected or even an early cancer etc.
> BTW that's how it works for my dentist.
No it doesnt. If you do develop a serious infection as the
result of say a crown, he does not fix that entirely at his cost.
> He says (say) he's got to put
> in a crown at [tooth number]; he sends all the paperwork and x-rays to
> the insurance company and they approve in advance in writing telling
> him how much he has to collect from me (the customer). He says he's
> never had a problem with the insurance company not paying later on and
> if they didn't he would consider that between him and them, nothing he
> could recharge to the customer.
But likely did have a problem when a patient got an infection etc.
Gordon Burditt
>> disgraceful and really not understandable why the courts won't
>> intervene and stop these practices. If you ask for your car to be
>> repaired and the garage gives you a quote that's the maximum they can
>> collect. Why should the human/doctor be any different?
>
>Oh, my doc could absolutely give fixed quotes for cash prices for office
>visits and procedures.
I doubt it. There are at least three sets of prices:
1. The amount the doctor bills the insurance company. This cost is pretty
much irrelevant to the insured. It could hurt the uninsured a lot.
2. The contract amount for the procedure. An in-network doctor can't
charge more than this amount. This amount gets paid by the insurance
company and the patient, divided somehow.
3. The amount paid by the patient. This can be affected by things like
how much deductible he hasn't used yet.
*ALL THREE* of those prices are highly variable depending on your insurance
company.
>It's what the patient ends up paying after
>insurance is no guarantee. And I doubt that your local mechanic ever
>has to tell you what you will end up paying after your insurance company
>pays. Not only that, but a car has a finite and constantly decreasing
>value. Can you see some insurance company saying, "I'm sorry, you have
>maxed out your lifetime benefits for health care and we are 'totalling'
>you. We will settle your case for $$ and you will have to take care of
>any further medical costs out of your pocket for the rest of your life;
>alternatively, if you present to the local euthanasia center for
>disposal and provide proof, you can get a higher figure for being
>totalled and disposed of." That sounds pretty immoral and intolerable
>to me.
I expect government health care to do just this sort of thing,
and I expect that it's already being done in some situations, like
not giving a 93-year-old man a heart transplant.
>And that is why health insurance is so different than medical
>insurance.
Would you care to define "health insurance", "medical insurance", and
state the difference between the two?
>Now, if health insurance worked like car insurance, then the patient
>would have to pay the bill and then be reimbursed by the insurance
>company,
Some medical services work exactly like that: for example, flu
shots. You pay for the flu shot, and they give you a receipt and
YOU file a claim with your insurance company. I've also seen the
same thing happen with more expensive procedures like a non-routine
root canal requiring a specialist. These guys *can* give you a (large)
price and stick to it. You can talk to your insurance company to see
how much they will pay.
>or the insurance company would have a fixed amount they would
>pay and they could pay it to the insurance company no questions asked.
>
>Unfortunately, the doc's office is not allowed to bill the patient until
>he has first billed the primary insurance, then after the primary
>insurance has paid he has to bill any secondary insurance (and if the
>patient messed up on giving the doc's office the proper insurance, that
>gets all messed up)
Some medical services decidedly do *NOT* work that way. The doctor
doesn't communicate with the insurance company.
>I think that if the insurance companies dealt directly with the patients
>and just reimbursed the patients for allowable costs instead of the
>doctors having to fight with them about getting paid, then it wouldn't
>be quite such a tangled mess for anybody.
Yes, it would be a tangled mess, with the patient having to pass messages
between the insurance company and the doctor.
Gordon Burditt
>> health care reform should have corrected but probably didn't. It's
>> disgraceful and really not understandable why the courts won't
>> intervene and stop these practices. If you ask for your car to be
>> repaired and the garage gives you a quote that's the maximum
>> they can collect. Why should the human/doctor be any different?
>
>Essentially because its nowhere near as easy to predict
>what total services the individual needs with a serious
>medical problem, like for example when the individual
>ends up with a very serious infection that costs a hell
>of a lot to fix. You dont get anything like that with cars.
You can get something like that with cars. For example, you bring
in the car, badly overheating, and they diagnose it as a cracked
radiator, and quote you a (large) price. (Up to this point, this
really happened. Yes, the crack was real; I pointed it out to
them.) *LATER*, after they've fixed the radiator, they try to test
the engine and discover that the block is cracked from severe
overheating due to the cracked radiator. (What really happened
here was they tested the engine and decided it wasn't harmed by the
overheating. Apparently repeatedly stopping and refilling the
radiator with water helped prevent damage while limping home.)
They'll stick to their quote on fixing the radiator, but they won't
include a free replacement engine block in the deal.
It isn't that unusual to discover that one part failing takes out
another part also (on both cars and humans).
Rod Speed
>>> It's disgraceful and really not understandable why the courts won't
>>> intervene and stop these practices. If you ask for your car to be
>>> repaired and the garage gives you a quote that's the maximum
>>> they can collect. Why should the human/doctor be any different?
>> Oh, my doc could absolutely give fixed quotes for cash prices for office visits and procedures.
> I doubt it.
Its true anyway.
> There are at least three sets of prices:
And you forgot the most important one in that particular situation.
> 1. The amount the doctor bills the insurance company. This cost is
> pretty much irrelevant to the insured. It could hurt the uninsured a lot.
> 2. The contract amount for the procedure. An in-network doctor can't
> charge more than this amount. This amount gets paid by the insurance
> company and the patient, divided somehow.
> 3. The amount paid by the patient. This can be affected by things
> like how much deductible he hasn't used yet.
4. The amount of cash he will accept for a particular office visit
and proceedure when he has no involvement what so ever with any
insurance company at all, because he is paid in cash by the patient.
> *ALL THREE* of those prices are highly variable depending on your insurance company.
And FOUR involves no insurance company whatever as far as the doctor is concerned.
>> It's what the patient ends up paying after
>> insurance is no guarantee. And I doubt that your local mechanic ever
>> has to tell you what you will end up paying after your insurance
>> company pays. Not only that, but a car has a finite and constantly
>> decreasing value. Can you see some insurance company saying, "I'm
>> sorry, you have maxed out your lifetime benefits for health care and
>> we are 'totalling' you. We will settle your case for $$ and you
>> will have to take care of any further medical costs out of your
>> pocket for the rest of your life; alternatively, if you present to
>> the local euthanasia center for disposal and provide proof, you can
>> get a higher figure for being totalled and disposed of." That
>> sounds pretty immoral and intolerable to me.
> I expect government health care to do just this sort of thing,
It doesnt, most obviously when you end up with
a serious infection as a result of the surgery etc
or when its discovered that you have cancer when
they open you up and it makes sense to remove
the cancer when it has been discovered etc.
> and I expect that it's already being done in some situations,
Yes, when there are no unexpected complications.
> like not giving a 93-year-old man a heart transplant.
That happens with the insurance system too when there
are no suitable donor hearts available and that individual
is well down the queue and gets to die without getting one.
The cost of the medical services that they need before
they end up dead tho cannot be predicted in advance.
No govt operation just decides that an individual is too old to ever
end up with a transplant and so they just yawn and dont provide
any further treatment because the individual will die sometime.
>> And that is why health insurance is so different than medical insurance.
> Would you care to define "health insurance", "medical insurance",
> and state the difference between the two?
>> Now, if health insurance worked like car insurance, then the patient would
>> have to pay the bill and then be reimbursed by the insurance company,
> Some medical services work exactly like that: for example,
> flu shots. You pay for the flu shot, and they give you a
> receipt and YOU file a claim with your insurance company.
Even those dont work like that if you end up with a bad result from the flu shot.
> I've also seen the same thing happen with more expensive procedures
> like a non-routine root canal requiring a specialist. These guys *can*
> give you a (large) price and stick to it. You can talk to your insurance
> company to see how much they will pay.
But that still doesnt cover the situation where you end up with a serious infection.
Rod Speed
>>> You're probably correct and this is one of the things the recent
>>> health care reform should have corrected but probably didn't. It's
>>> disgraceful and really not understandable why the courts won't
>>> intervene and stop these practices. If you ask for your car to be
>>> repaired and the garage gives you a quote that's the maximum
>>> they can collect. Why should the human/doctor be any different?
>> Essentially because its nowhere near as easy to predict
>> what total services the individual needs with a serious
>> medical problem, like for example when the individual
>> ends up with a very serious infection that costs a hell
>> of a lot to fix. You dont get anything like that with cars.
> You can get something like that with cars.
Nope, nothing like it. With a car where it turns out that when
the part is removed, its clear that the engine is completely
fucked beyond any possibility of economic repair, they can
always ring you and ask you what you want to do about that,
whether you want to pay for a new engine as well etc.
> For example, you bring in the car, badly overheating, and they
> diagnose it as a cracked radiator, and quote you a (large) price.
> (Up to this point, this really happened. Yes, the crack was real;
> I pointed it out to them.) *LATER*, after they've fixed the radiator,
> they try to test the engine and discover that the block is cracked
> from severe overheating due to the cracked radiator. (What really
> happened here was they tested the engine and decided it wasn't
> harmed by the overheating. Apparently repeatedly stopping and
> refilling the radiator with water helped prevent damage while limping
> home.) They'll stick to their quote on fixing the radiator, but they won't
> include a free replacement engine block in the deal.
And so its not the same thing as when you develope a serious
infection as a RESULT of the surgery and they certainly dont
have the option to just let the individual die when it got infected.
> It isn't that unusual to discover that one part failing
> takes out another part also (on both cars and humans).
Sure, but with the car, you are welcome to decide that the
car is not economic to repair and should be scrapped when
that is discovered. Not too many patients are too keen on
being told that it was discovered that they had cancer when
they were opened up and since that was not included in the
original quote, they didnt bother to do anything about the
cancer they discovered or just yawned and decided that
the individual had passed its useby date and did the
hernia anyway, since the patient had agreed to pay for that.
MAS
> I expect government health care to do just this sort of thing,
> and I expect that it's already being done in some situations, like
> not giving a 93-year-old man a heart transplant.
>
That's a generous age estimate. Around my area, you won't be considered
for a heart transplant if you're over 65, unless you're somebody famous.
Marsha
Samantha Hill
>
> I have had them ask me to sign a paper to pay the procedure
> in advance otherwise they cancel the procedure. I asked
> Medicare and they said the doctor can ask for money at time
> of service, not wait for them to do their figuring. So I
> think you're wrong about having to bill insurance first and
> then the patient.
They can ask the patient to pay up front if the patient has not assigned
their insurance benefits to the doctor, but if the patient assigns their
insurance benefits to the doctor, then the doctor cannot bill the
patient until all insurance policies have been billed and collected
from. And if I have it wrong, then I have heard many, many
conversations between the biller and various insurance companies and
patients to this effect while trying to get bills paid for that have
been wrong.
> The problem is the doctor is resisting any attempt by the
> patient to find the costs. This results in patients getting
> hit with huge medical bills that often bankrupt them when
> they are unable to obtain an idea of the costs of a treatment
> or procedure.
Well, if the doctor is not telling the patient what the cash-pay price
is, that is a problem. But if the doctor is not telling the patient
what their share will be after their insurance kicks in, the doctor
honestly will have no idea because the insurance companies will not tell
the doctor, since there are factors such as deductibles, out-of-network
differentiation in costs, etc. That's why I asked, was the patient
asking for a cash-pay price or what his share would be after the
insurance paid.
> Some of these guys may be getting kickbacks or other money
> from facilities they send all their patients to. Not
> providing costs on request may be an attempt to hide these
> hidden costs and hidden profits to the patient.
I am not denying that this does happen. I am just saying that there are
perfectly good reasons why a doctor does not want to use a particular
facility. A few weeks back, our doc had to do a procedure at one
particular facility that was the only one approvied by the insurance
company where he doesn't care to do procedures because of things like
what happened that time -- they have the whole list of equipment and
supplies he needs to do the procedure, but they were missing some
important piece and he had to do a makeshift job with something else,
which made it more difficult for him and more risky for the patient.
Samantha Hill
>
> Ok point taken. However, if a doctor does thousands of the
> same procedure, same codes at the same facility and then
> CLAIMS he has no idea of the costs, something is very fishy.
> Also using the same insurance companies.
They may be the same insurance companies, but insurance companies have
multiple plans, so it's not like everybody with Blue Cross has exactly
the same coverage. Every employer can have different options. As I
said, the doc knows EXACTLY what his cash-pay price is and he quotes
cash-pay prices to patients all the time, but for those with insurance,
he refers them back to their insurance company to get the scoop, because
the insurance company will not tell us.
> Look at all these
> people that are made poor by hidden medical costs. I have
> noticed many physicians are not adverse to padding the bills
> to Medicare with very high claims for procedures that pay
> alot less when billed under an HMO or private party.
That's ridiculous, because Medicare has fixed amounts that they will pay
regardless of what the physician charges -- and many insurance companies
base their payments on a certain percentage of Medicare (typically 90%
of Medicare at our office)
> Clean up medicine. Make it more honest. Doctors should take
> some leadership in this and that does not mean these jerks
> that try to get patients to pay several thousand dollars in
> advance and refuse all insurance.
Unfortunately, the insurance companies are holding all the cards.
Samantha Hill
>> Actually, I think that if the insurance company says, "We will authorize
>> this procedure and pay $$$ as per our contracted rate," then they should
>> be made to pay it.
>
> Perhaps because the insurance company and the MD have a contract? Ya
> know, the "contracted rate" you refer to. If they agree to an amount
> and then don't pay, the MD's argument is with the insurance company
> not the customer.
The contract with the MD and insurance company is not for coverage; it
is only for payment rates. The MD is not the customer of the insurance
company, and the insurance company certainly is not the customer of the
doctor. There have been many times at our office when the insurance
company reneged, and the doctor has absolutely NO recourse because the
insurance company holds all the cards.
I suppose the simplest solution for the doctor would be to say, "I will
not take patients who want me to assign their insurance benefits to me.
I will only take patients who will pay me directly and then collect
their insurance benefit themselves." This is how practically every
other business operates.
> Depending on the insurance, you might have an
> insurance-owned body shop which does the work with no cost to you
> other than the deductible or a private shop which negotiates an amount
> (usually a quote) with the insurance company usually via a loss
> assessor. No surprises!
Well, if you are saying that the doctor should own everything so he can
control costs, then what about the people who don't want to go to a
facility owned by the doctor because they are convinced that he/she will
be getting kickbacks?
I have Kaiser Permanente insurance. Everybody in Kaiser is an employee,
not an independent contractor. They control costs well because they
have their hand on everything, and patients generally don't get
surprised by bills that the insurance company sticks them with. I agree
that this is a very efficient model. On the other hand, I fear for one
entity owning all the health-care insurance in this country because I
have seen lots of bad situations where a patient's health care was
controlled by one gatekeeper, and I don't want to see that happen. I
had a friend who suffered from specific medical problem for years
because she had one gatekeeper for her health care who would only
consider one treatment for the problem that was an unacceptable solution
to her and refused to consider other equally-valid and equally-respected
treatments well known to the medical community at large. So I would
oppose a gatekeeper-type approach to health care.
Samantha Hill
>
> Essentially because its nowhere near as easy to predict
> what total services the individual needs with a serious
> medical problem, like for example when the individual
> ends up with a very serious infection that costs a hell
> of a lot to fix. You dont get anything like that with cars.
Actually, I did once. I hit something on the freeway at night with my
car and it did a lot of damage to my engine, and they really couldn't
see everything that was wrong until they started getting in there and
taking everything apart.
Other than that, I think you are spot-on.
Samantha Hill
>
> Nope, nothing like it. With a car where it turns out that when
> the part is removed, its clear that the engine is completely
> always ring you and ask you what you want to do about that,
> whether you want to pay for a new engine as well etc.
And if some people here had their say, I guess the auto mechanic should
just eat that cost because it was higher than the estimate, right? I
don't think so.
I was shocked when President Obama said that doctors should not be paid
for their services if they don't cure the patient. Human beings are not
built to a standard, and there is no one-size-fits-all solution to every
problem a human being can come across.
Samantha Hill
>> Oh, my doc could absolutely give fixed quotes for cash prices for office
>> visits and procedures.
>
> I doubt it. There are at least three sets of prices:
> 1. The amount the doctor bills the insurance company. This cost is pretty
> much irrelevant to the insured. It could hurt the uninsured a lot.
>
> 2. The contract amount for the procedure. An in-network doctor can't
> charge more than this amount. This amount gets paid by the insurance
> company and the patient, divided somehow.
>
> 3. The amount paid by the patient. This can be affected by things like
> how much deductible he hasn't used yet.
>
> *ALL THREE* of those prices are highly variable depending on your insurance
> company.
But that's not what a cash-pay price is. A cash-pay price is what the
doctor will charge if he doesn't have to get involved with any insurance
company. So your response had nothing to do with what you were
responding to.
>> And that is why health insurance is so different than medical
>> insurance.
>
> Would you care to define "health insurance", "medical insurance", and
> state the difference between the two?
Sorry -- I meant "why auto insurance is so different than medical
insurance."
>> Now, if health insurance worked like car insurance, then the patient
>> would have to pay the bill and then be reimbursed by the insurance
>> company,
>
> Some medical services work exactly like that: for example, flu
> shots. You pay for the flu shot, and they give you a receipt and
> YOU file a claim with your insurance company. I've also seen the
> same thing happen with more expensive procedures like a non-routine
> root canal requiring a specialist. These guys *can* give you a (large)
> price and stick to it. You can talk to your insurance company to see
> how much they will pay.
That is when the patient has not assigned their insurance benefits to
the doctor. That is more difficult for the patient to manage, but it
worked for years.
>> Unfortunately, the doc's office is not allowed to bill the patient until
>> he has first billed the primary insurance, then after the primary
>> insurance has paid he has to bill any secondary insurance (and if the
>> patient messed up on giving the doc's office the proper insurance, that
>> gets all messed up)
>
> Some medical services decidedly do *NOT* work that way. The doctor
> doesn't communicate with the insurance company.
Well, when the patient has assigned their insurance benefits to the
doctor, that is exactly how it works. If the patient has not assigned
their insurance benefits to the insurance company, then it doesn't. And
for the record, I have never been to a dentist who has allowed me to
assign my insurance benefits to them.
>> I think that if the insurance companies dealt directly with the patients
>> and just reimbursed the patients for allowable costs instead of the
>> doctors having to fight with them about getting paid, then it wouldn't
>> be quite such a tangled mess for anybody.
>
> Yes, it would be a tangled mess, with the patient having to pass messages
> between the insurance company and the doctor.
That's how it all used to work 30 or 40 years ago or so. So what you
are saying is that the tangled mess needs to be transferred from the
patient to the doctor, I guess. There is no reason why a patient who
takes their itemized medical bill and presents it to their insurance
company for payment should have to pass messages between the insurance
company and the doctor.
Rod Speed
> Rod Speed wrote
>> Essentially because its nowhere near as easy to predict
>> what total services the individual needs with a serious
>> medical problem, like for example when the individual
>> ends up with a very serious infection that costs a hell
>> of a lot to fix. You dont get anything like that with cars.
> Actually, I did once.
Nope.
> I hit something on the freeway at night with my car and it did a lot of damage to my engine, and they really couldn't
> see everything that was wrong until they started getting in there and taking everything apart.
Thats nothing like a serious problem that was
PRODUCED by the attempt to fix the car.
Thats closer to the other situation where, once they open
the patient up, they discover that the individual has cancer
and that wasnt obvious when they quoted for surgery for
a completely different problem.
Rod Speed
> Rod Speed wrote
>> Nope, nothing like it. With a car where it turns out that when
>> the part is removed, its clear that the engine is completely
>> beyond any possibility of economic repair, they can
>> always ring you and ask you what you want to do about that,
>> whether you want to pay for a new engine as well etc.
> And if some people here had their say, I guess the auto mechanic
> should just eat that cost because it was higher than the estimate, right?
Sure, some do run that line, but its clearly a completely unreasonable proposition.
> I don't think so.
I dont either.
> I was shocked when President Obama said that doctors should not be paid for their services if they don't cure the
> patient.
Yeah, he's fool.
> Human beings are not built to a standard, and there is no one-size-fits-all
> solution to every problem a human being can come across.
And anyone with even half a clue wants decent medical services even
if that is just ameliorating the symptoms of an incurable cancer etc.
Mate of mine has just died of an incurable cancer. His quality
of life was much better towards the end because the medical
system dealt with the secondarys appropriately, even tho it
was obvious that those were going to kill him eventually.
Joh...@badisp.org
>Joh...@BadISP.org wrote:
>> Samantha Hill <sam...@samhillsonic.net> wrote:
>> You're probably correct and this is one of the things the recent
>> health care reform should have corrected but probably didn't. It's
>> disgraceful and really not understandable why the courts won't
>> intervene and stop these practices. If you ask for your car to be
>> repaired and the garage gives you a quote that's the maximum
>> they can collect. Why should the human/doctor be any different?
>Essentially because its nowhere near as easy to predict
>what total services the individual needs with a serious
>medical problem, like for example when the individual
>ends up with a very serious infection that costs a hell
>of a lot to fix. You dont get anything like that with cars.
Yes you do. In your case the infection could have been caused by the
intervention (e.g. the problem of MRSA) where it's analogous to the
mechanic, after making repairs to the engine, testing your car without
putting oil in the engine. The engine seizes up and usually the
mechanic is liable for the damage he caused. Alternatively if he can
show it wasn't his fault he can escape the cost of the new engine and
ask the owner what he (the owner) wants to do.
In any event, if the patient (how I hate that demeaning word) is able
to make a decision on his own (he's conscious and of sound mind) the
MD asks him and as part of the asking he tells the patient exactly how
much it is going to cost. How much will be paid by the insurance, how
much by the patient, how much by the malpractice lawsuit. Except for
the cost aspect he has to do this anyway under the doctrine of
informed consent.
If the patient is non-compos-mentis, and the surgery is elective, the
patient should have appointed a person to act on his behalf (same
informed consent doctrine). All that has to be done is to extend that
to "How much, buddy."
Only for emergency surgery would there be any excuse for not providing
a quote in advance and the options to decline etc.
>> The MD should provide a quote in writing after asking the insurance
>> company. If later on they renege (or so he says) he (the MD) eats it!
>It cant work like that with major surgery. There is always the possibility
>of a very serious infection or even once the individual is opened up, the
>surgeon discovers that the individual has a much more complicated
>physiology than was expected or even an early cancer etc.
You keep going on about this serious infection etc, but in these cases
in elective surgery the patient should have made his decisions in
advance. In any event I'd settle for a quote for uneventful surgery
until the MD's are whipped into line.
>> BTW that's how it works for my dentist.
>No it doesnt. If you do develop a serious infection as the
>result of say a crown, he does not fix that entirely at his cost.
Huh? On about this serious infection again. If you develop some
infection as a result of his setting of the crown the dentist should
be worried about lawsuits, not the minor cost of antibiotics.
>> He says (say) he's got to put
>> in a crown at [tooth number]; he sends all the paperwork and x-rays to
>> the insurance company and they approve in advance in writing telling
>> him how much he has to collect from me (the customer). He says he's
>> never had a problem with the insurance company not paying later on and
>> if they didn't he would consider that between him and them, nothing he
>> could recharge to the customer.
>But likely did have a problem when a patient got an infection etc.
Oh, get off the infection kick. Only in abnormal circumstances would
the dentist not know this in advance (e.g. an abscess) and treat it
separately before putting in a crown. The insurance would also pay
separately.
Rod Speed
> Rod Speed <rod.sp...@gmail.com> wrote
>> Joh...@BadISP.org wrote
>>> Samantha Hill <sam...@samhillsonic.net> wrote
>>> You're probably correct and this is one of the things the recent
>>> health care reform should have corrected but probably didn't. It's
>>> disgraceful and really not understandable why the courts won't
>>> intervene and stop these practices. If you ask for your car to be
>>> repaired and the garage gives you a quote that's the maximum
>>> they can collect. Why should the human/doctor be any different?
>> Essentially because its nowhere near as easy to predict
>> what total services the individual needs with a serious
>> medical problem, like for example when the individual
>> ends up with a very serious infection that costs a hell
>> of a lot to fix. You dont get anything like that with cars.
> Yes you do.
No you dont.
> In your case the infection could have been caused by
> the intervention (e.g. the problem of MRSA) where it's
> analogous to the mechanic, after making repairs to the
> engine, testing your car without putting oil in the engine.
Nope, nothing like. Thats just an incompetant repair, the equivalent
to the doctor leaving as swab or an instrument in the individual etc.
The doctor isnt legally responsible for the MRSA infection.
The mechanic is legally responsible for not putting oil in the engine.
> The engine seizes up and usually the mechanic is liable for the damage he caused.
They always are.
> Alternatively if he can show it wasn't his fault
Not even possible if he failed to put any oil in the engine after the repair.
> he can escape the cost of the new engine and
> ask the owner what he (the owner) wants to do.
Only if he lies about what happened.
> In any event, if the patient (how I hate that demeaning word)
I hate the even sillier alternatives like customer or client even more.
> is able to make a decision on his own (he's conscious and of sound mind)
> the MD asks him and as part of the asking he tells the patient exactly
> how much it is going to cost. How much will be paid by the insurance,
The doctor cant tell you that with the stupid american system.
> how much by the patient, how much by the malpractice lawsuit.
He cant tell you that either.
> Except for the cost aspect he has to do this anyway under the doctrine of informed consent.
But its never going to be possible to accurately quantify the risk of
an infection, or the risk that the individual may have a very unusual
physiologogy or an unusual lack of response to medication etc etc etc.
> If the patient is non-compos-mentis, and the surgery is elective,
> the patient should have appointed a person to act on his behalf
> (same informed consent doctrine). All that has to be done is to
> extend that to "How much, buddy."
And its never feasible to cover all possibilitys on that cost question,
particularly with infection or when the doctor discovers that the
individual has some other condition as well that affects the outcome.
> Only for emergency surgery would there be any excuse for
> not providing a quote in advance and the options to decline etc.
All the quote can ever do is provide an estimate of what the bulk of
those proceedures cost, assuming no unusual infection or physiology
or drug response etc etc etc. And so that quote cannot be legally
binding on the doctor in the sense that they arent allowed to charge
any more even if the shit does hit the fan during the proceedure etc.
Hardly anyone would be happy with the doctor just yawning when
the individual gets a serious infection as a result of the surgery and
says that since that wasnt included in the quote, you get to die etc.
>>> The MD should provide a quote in writing after asking the insurance
>>> company. If later on they renege (or so he says) he (the MD) eats it!
>> It cant work like that with major surgery. There is always the
>> possibility of a very serious infection or even once the individual
>> is opened up, the surgeon discovers that the individual has a much
>> more complicated physiology than was expected or even an early
>> cancer etc.
> You keep going on about this serious infection etc,
Because its the most common reason that it isnt feasible
to provide a quote that will never be exceeded.
You dont even get that with a car, there are always some
situations where you are given a quote for an engine repair and
when it turns out that the engine is much worse than it appeared
to be, you get a choice of abandoning repair, and paying for the
work already done, or paying more for a new engine etc.
> but in these cases in elective surgery the patient
> should have made his decisions in advance.
Not even possible to anticipate all that might happen, including
the surgeon having a heart attack while doing the surgery etc.
> In any event I'd settle for a quote for uneventful
> surgery until the MD's are whipped into line.
They cant ever be whipped into line, because its never
going to be possible to anticipate all complications.
>>> BTW that's how it works for my dentist.
>> No it doesnt. If you do develop a serious infection as the
>> result of say a crown, he does not fix that entirely at his cost.
> Huh? On about this serious infection again.
Because that is the most common cause of unexpected costs.
> If you develop some infection as a result of his setting of
> the crown the dentist should> be worried about lawsuits,
Only in the stupid american system. The individual may itself
have been where the MRSA infection came from and it is most
likely that the individual's compromised immune system is the
reason they ended up with an infection. Neither is something
that the dentist is legally responsible for in any viable legal system.
> not the minor cost of antibiotics.
The cost can be a hell of a lot more than minor with an antibiotic resistant infection.
>>> He says (say) he's got to put
>>> in a crown at [tooth number]; he sends all the paperwork and x-rays
>>> to the insurance company and they approve in advance in writing
>>> telling him how much he has to collect from me (the customer). He
>>> says he's never had a problem with the insurance company not paying
>>> later on and if they didn't he would consider that between him and
>>> them, nothing he could recharge to the customer.
>> But likely did have a problem when a patient got an infection etc.
> Oh, get off the infection kick.
Demand denied. That is the most common cause of unexpected costs.
> Only in abnormal circumstances would the dentist not know this in advance
> (e.g. an abscess) and treat it separately before putting in a crown.
Wrong.
> The insurance would also pay separately.
You havent established that there is any insurance.